“We’ve been waiting here for an hour already! My kid is sick—he threw up three times today!” a father complained to the triage nurse. Meanwhile, his boy sat kicking his untied sneakers against the chair legs, fingers tapping his iPad, vomit bag cast aside.
As usual for a Sunday evening, the chairs of the pediatric emergency department (ED) waiting room were full. In the corner sat a 12-year-old boy with three days of an itchy rash, still scratching despite using a cream from his doctor. The rash spread today, so she wanted him seen again.
Nearby, a 10-day-old baby slept snug in her car seat. Her poops that night had turned yellow and seedy, worrying her exhausted mother.
A 6 year-old boy stood mesmerized by the fish darting in the waiting room tank. He’d had fevers and joint pain off-and-on for weeks. His parents couldn’t risk time off from their jobs cleaning hotel rooms 12 hours a day to make it to their community clinic, so they came here at 8 p.m. instead.
The teenage girl in the back had menstrual cramps, but she had runout of ibuprofen. She figured she could get some prescribed here.
Another infant of 3-months was sleeping in his car seat by the window. He was brought in for twitching oddly every day for a few weeks. His parents were recent refugees from Laos and didn’t speak any English. A neighbor told them someone in the ED would be able to communicate with them through the telephone interpreter. They all sat, shifting impatiently in their stiff seats.
Enter a frantic mother with her nut-allergic toddler who was wheezing and vomiting, with his lips swollen and face blooming with hives. She ran straight to the desk and was ushered swiftly through the swinging doors of the ED. “Why did she get to go in right away?” a mother shouted at the triage nurse. “My kid’s been here an hour already.”
In the ED, patients often wonder why they aren’t seen fast enough, or why their problems aren’t completely solved, or why the tests they want cannot be ran by us. Doctors and nurses in the ED also grumble and ask each other, “Why did the patient come here for that? Don’t they know this isn’t the place for such issues? Why didn’t they go to their pediatrician’s office in the morning?”
And pediatricians bemoan, “Why did my patient go to the ER for that? Why didn’t they call our office first?”
The answers to these questions are often more complex and diverse than copays or convenience. They can stem from perverse incentives, an on-demand culture, a distrust of physicians, a strained Primary Care system, or sometimes just no one nearby to teach you to sip Gatorade and nibble Saltines at home when you’re vomiting.
Those of us working in the ED are best equipped to care for emergent conditions, but we will care for any and all who arrive at our doors. If it’s not too busy, I’m more than happy to spend 40 minutes troubleshooting your challenges breastfeeding, but I also don’t want your delicate newborn exposed to someone else’s child with whooping cough or meningitis in the ED waiting room.
We want patients to get the right care—when they need it, where they can best be helped, and from the person with the appropriate expertise. What can be done to achieve this? As physicians, we can be more explicit about what type of care and where it is delivered. We know why certain tests can’t be sent from the ED, when a specialist is helpful (or not), or how best to arrange a routine MRI. But patients rarely understand these systems issues. We can explain the benefits of a medical home, emphasizing how diagnosis and management of illness happens through observing its pattern or progression, made easier when the same person who can track the entire arc of an illness. We can remind patients frequently after-hours through call systems on how they can save an ED visit. We can work to improve access to care overall with legislative advocacy, integration of telemedicine, or shifting office hours.
As patients, we can call our Primary Care offices or local nurse advice lines first (as long as we are alert and breathing). They can be particularly helpful in figuring out what is (and is not) considered a medical emergency, often saving a copay, a long wait, a night without much sleep, and a risk of exposure to other illnesses. We can educate ourselves about our health using reliable sources such as doctors, nurses, reputable websites, books, grandparents, or others who’ve had similar illnesses. We are not the first parents to nurse our children through croup, gastroenteritis, or hives. A grandma’s advice can help. We can find a Primary Care practice we reliably access and then use it. If we don’t trust the care, we can find a provider that’s a better fit.
All of us can advocate for systemic change by supporting policies that help people give and receive the right care in the right place, such as home visit programs for newborns or the elderly; no copays for Primary Care visits; equitable compensation for Primary Care physicians; incentives to practice in underserved areas; public health education; paid sick leave; or access to insurance that actually provides good coverage.
Above all, we can give each other grace. Doctors: We can remember that patients are stressed, tired, and just trying to find answers and help, and the ED may be the only place they know to look. Patients: Realize your doctor is caring for many—some not so sick, others dying—and in the end just wants to give good care in a complex system. No one likes sitting for hours in ED waiting rooms, but we can each do our part to make them less crowded.
Dr. Julia Michie Bruckner is a pediatrician, mother, survivor of recurrent cancer, writer and 2018-2019 Doximity Author. You can find her at www.juliamd.com and @JuliaMDWriter.
